59YR/M With fever ,cough,cold since 4 days

 70 year old female patient with Shortness of Breath 

9th March 2023 

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59 year old male patient with Fever,cough,cold

Dr. M. Prathyusha ( Intern )

Roll no : 96

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

CASE :  

59 year old male patient farmer by occupation came to opd with complaints of 

1. Fever since 4 days

2.cough since 4 days

3. Cold since 4 days

HOPI : 

Patient was apparently asymptomatic 4 days ago, then he had fever which was insidious in onset , gradually progressive,low grade , intermittent , associated with chills and rigors , relieved by medication.

Fever associated with cold and cough since 4 days.

C/o cough since 4 days which is productive,whitish mucoid sputum,not blood tinged ,non foul smelling.

C/o pain in left knee joint and left hand since 1 yr.

C/o generalised weakness.

No H/o  burning micturition , pain abdomen , palpitations , vomitings , loose stools,sob,chest pain.

PAST HISTORY :

Not a k/c/o DM, HTN , TB ,epilepsy, asthma,CAD,CVD, thyroid disorders.

PERSONAL HISTORY:

Appetite- Normal

Diet - mixed 

Bowel - regular 

Bladder - Normal

Addictions - ocassional , stopped 5-6 months back.

FAMILY HISTORY:

No significant family history 

GENERAL EXAMINATION:

Pt is C,C,C 

No pallor, icterus , cyanosis, clubbing, lymphadenopathy , pedal edema 

Vitals - 

Temp -99.5F

PR - 98bpm

BP - 90/60 mmhg

RR - 20cpm

SpO2 - 99% at Room air 

GRBS- 108 mg/dl

SYSTEMIC EXAMINATION :

PER ABDOMEN :

Inspection :

Umbilicus is central and inverted

All quadrants are moving equally with respiration 

No sinuses , engorged veins, visible pulsations .

Hernial orifices are free

Palpation :

Abdomen is soft in consistency.

No organomegaly.

Liver and Spleen - Not palpable 

Percussion : Tympanic note heard over the abdomen.

Auscultation:

Bowel sounds are heard.

CARDIOVASCULAR SYSTEM:

Inspection:

Shape of chest is elliptical. 

No raised JVP

No visible pulsations, scars , sinuses , engorged veins.

Palpation:

Apex beat - felt at left 5th intercostal space

No thrills and parasternal heaves

Auscultation :

S1 and S2 heard. 

RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

bilateral air entry present. Normal vesicular breath sounds heard.

CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes  -   Right    Left

Biceps          ++          ++

Triceps.        ++          ++

Supinator     +            +

Knee              ++          ++

Ankle             ++        ++

INVESTIGATIONS:

CBP:

Hb - 13.4 gm/dl

TLC - 11000cells/ cumm

RBC - 4.33 million

PLT - 3.05 lakh

CUE :

Albumin- Trace

Sugars - nil

RFT: 

urea - 39mg/dl

Creatinine - 1.0mg/dl

uric acid -4.2mg/dl

Ca+2 - 9.9mg/dl

Na - 138 mEq/L

K - 3.7 mEq/L

Cl -  101mEq/L 

LFT :

TB- 0.91mg/dl

DB- 0.21 mg/dl

SGPT -10  IU/L

SGOT - 15 IU/L

ALP - 106IU/L

TP - 6.0 gm/dl

albumin - 3.3gm/dl 

A/G ratio- 1.25

CRP (9/3/23)- POSITIVE (1.2ng/dl)

ESR(9/3/23)- 40mm/hr

ECG-

Chest x ray -

2D echo-

USG abdomen -

PROVISIONAL DIAGNOSIS : 

Pyrexia under evaluation

? LRTI

TREATMENT :  

1.IVF NS @100 ML/HR

2. INJ. OPTINEURON @ 100ml /hr

3. TAB.DOLO 650 mg po SOS

4. TAB. LEVOCETRIZINE 5 mg po od

5. SYP. ASCORYL LS 1TSP po TID

6. T.ZINCOVIT PO/OD

SOAP NOTES:

9/3/23

Admission date: 08/03/23

Ward

Unit-6

Dr.usha(SR)

Dr.Shashikala(PGY3)

Dr.Keerthi(PGY2)

Dr.Nithin(PGY1)

Dr.Prathyusha(Intern)

Dr.Ankitha(Intern)

S 

No fever spike , stools passed, cough reduced

O

Pt is conscious , coherent , cooperative

BP-100/70mmhg 

PR- 92bpm

Temp- 98.6F

RR- 20 cpm

GRBS- 95 mg/dl

CVS- S1,S2 heard, no murmurs 

RS- BAE (+), NVBS(+)

P/A-soft, non-tender , no organomegaly

Bowel sounds(+)

CNS: NAD 

A

Pyrexia under evaluation?LRTI

P

1.IVF NS @100 ML/HR

 2.INJ. OPTINEURON @ 100ml /hr

3. TAB.DOLO 650 mg po SOS

4. TAB. LEVOCETRIZINE 5 mg po od

5. SYP. ASCORYL LS 1TSP po TID

6. T.ZINCOVIT PO/OD